Licensed Clinical Social Worker 4B

The University of the State of New York The State Education Department Office of the Professions Division of Professional Licensing Services Clinical Social Worker Form 4B Certification of Experience for Licensed Clinical Social Worker 1. Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 8. Use the psychotherapy log to document your hours of practice and supervision. This log must be completed by you and your supervisor. All pages of the log must be retained by the supervisor, in the event the State Board requests clarification. 2. Send the entire form along with a copy of Appendix A to your supervisor (if your supervisor is unavailable, you must provide the supervisor's qualifications and your experience may be verified by a Licensed colleague) and ask him/her to complete Section II and forward the entire form directly to the Office of the Professions at the address at the end of the form.

I am licensed and currently registered to practice as a (check all that apply) Licensed Clinical Social Worker

Loading..

Tags:

  Social, Clinical, Worker, Licensed, Licensed clinical social worker

Information

Related search queries